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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:15G30204/10/2017FORM

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Begin by filling out the personal details section, including the name, address, contact information, and any other required personal information.

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Proceed to the purpose of the visit section and provide a detailed explanation of why the visit is being made, such as a business meeting, medical appointment, or tourist visit.

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What is this visit was for?

This visit was for a compliance check by regulatory authorities.

Who is required to file this visit was for?

The compliance officer or the designated individual for the organization is required to file this visit.

How to fill out this visit was for?

The visit should be documented with details of the inspection, findings, and any corrective actions taken.

What is the purpose of this visit was for?

The purpose of this visit is to ensure that the organization is in compliance with regulations and standards.

What information must be reported on this visit was for?

Information such as date of visit, regulatory authorities involved, inspection details, findings, and corrective actions must be reported.

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